Current Cardiovascular Imaging Reports

, Volume 5, Issue 5, pp 375–382 | Cite as

Imaging of Myocardial Perfusion and Late Enhancement

Cardiac Computed Tomography (TC Villines and S Achenbach, Section Editors)


While coronary computed tomography angiography offers a noninvasive method to identify the presence or absence of coronary artery disease, the functional significance of anatomical lesions identified by this technique is often unknown. As a result, some patients may require further testing to assess for ischemia in order to help guide the need for further interventions. Recently, it has been recognized that cardiac CT is able to visualize rest and stress myocardial perfusion, thus enabling the possibility of evaluating the anatomical burden and physiological significance of coronary artery disease in a single exam. This article will provide an overview of CT perfusion and review the most recent developments relating to this new technique. The potential use of late enhancement imaging will also be discussed. Finally, an overview of the key research questions in this field will be presented followed by a discussion regarding the future direction of CT perfusion imaging.


Coronary artery disease Ischemia Myocardial perfusion imaging Computed tomography Myocardial infarction 


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Budoff MJ, Dowe D, Jollis JG, Gitter M, Sutherland J, Halamert E, et al. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol. 2008;52:1724–32.PubMedCrossRefGoogle Scholar
  2. 2.
    Meijboom WB, Van Mieghem CA, van Pelt N, Weustink A, Pugliese F, Mollet NR, et al. Comprehensive assessment of coronary artery stenoses: computed tomography coronary angiography vs conventional coronary angiography and correlation with fractional flow reserve in patients with stable angina. J Am Coll Cardiol. 2008;52:636–43.PubMedCrossRefGoogle Scholar
  3. 3.
    Miller JM, Rochitte CE, Dewey M, Arbab-Zadeh A, Niinuma H, Gottlieb I, et al. Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med. 2008;359:2324–36.PubMedCrossRefGoogle Scholar
  4. 4.
    Blankstein R, Di Carli MF. Integration of coronary anatomy and myocardial perfusion imaging. Nat Rev Cardiol. 2010;7:226–36.PubMedCrossRefGoogle Scholar
  5. 5.
    Di Carli MF, Dorbala S, Curillova Z, Kwong RJ, Goldhaber SZ, Rybicki FJ, et al. Relationship between CT coronary angiography and stress perfusion imaging in patients with suspected ischemic heart disease assessed by integrated PET-CT imaging. J Nucl Cardiol. 2007;14:799–809.PubMedCrossRefGoogle Scholar
  6. 6.
    Di Carli MF, Hachamovitch R. Hybrid PET/CT is greater than the sum of its parts. J Nucl Cardiol. 2008;15:118–22.PubMedCrossRefGoogle Scholar
  7. 7.
    Achenbach S. Anatomy meets function: modeling coronary flow reserve on the basis of coronary computed tomography angiography. J Am Coll Cardiol. 2011;58:1998–2000.PubMedCrossRefGoogle Scholar
  8. 8.
    Blankstein R, Cury R. Myocardial infarction imaging by CT. Curr Cardiovasc Imaging Rep. 2008;1:105–11.CrossRefGoogle Scholar
  9. 9.
    Blankstein R, Rogers IS, Cury RC. Practical tips and tricks in cardiovascular computed tomography: diagnosis of myocardial infarction. J Cardiovasc Comput Tomogr. 2009;3:104–11.PubMedCrossRefGoogle Scholar
  10. 10.
    Schepis T, Achenbach S, Marwan M, Muschiol G, Ropers D, Daniel WG, et al. Prevalence of first-pass myocardial perfusion defects detected by contrast-enhanced dual-source CT in patients with non-ST segment elevation acute coronary syndromes. Eur Radiol. 2010;20:1607–14.PubMedCrossRefGoogle Scholar
  11. 11.
    Blankstein R, Bolen MA, Pale R, Murphy MK, Shah AB, Bezerra HG, et al. Use of 100 kV vs 120 kV in cardiac dual source computed tomography: effect on radiation dose and image quality. Int J Cardiovasc Imaging. 2011;27:579–86.PubMedCrossRefGoogle Scholar
  12. 12.
    Ho KT, Chua KC, Klotz E, Panknin C. Stress and rest dynamic myocardial perfusion imaging by evaluation of complete time-attenuation curves with dual-source CT. JACC Cardiovasc Imaging. 2010;3:811–20.PubMedCrossRefGoogle Scholar
  13. 13.
    Bamberg F, Klotz E, Flohr T, Becker A, Becker CR, Schmidt B, et al. Dynamic myocardial stress perfusion imaging using fast dual-source CT with alternating table positions: initial experience. Eur Radiol. 2010;20:1168–73.PubMedCrossRefGoogle Scholar
  14. 14.
    • Feuchtner G, Goetti R, Plass A, Wieser M, Scheffel H, Wyss C, et al. Adenosine stress high-pitch 128-slice dual-source myocardial computed tomography perfusion for imaging of reversible myocardial ischemia: comparison with magnetic resonance imaging. Circ Cardiovasc Imaging. 2011;4:540–9. This study, which achieved the lowest reported radiation dose to date, investigated a protocol using a high pitch helical mode. The study is also notable for showing an excellent agreement between CTP and MRI perfusion.PubMedCrossRefGoogle Scholar
  15. 15.
    • Blankstein R, Shturman LD, Rogers IS, Rocha-Filho JA, Okada DR, Sarwar A, et al. Adenosine-induced stress myocardial perfusion imaging using dual-source cardiac computed tomography. J Am Coll Cardiol. 2009;54:1072–84. This study demonstrates feasibility and diagnostic accuracy of CT perfusion and late enhancement using the dual source CT. In this study, the diagnostic accuracy of CTP alone was comparable to SPECT imaging.PubMedCrossRefGoogle Scholar
  16. 16.
    • George R, Arbab-Zadeh A, Miller J, Kitagawa K, Chang H, Bluemke D, et al. Adenosine stress 64- and 256-row detector computed tomography angiography and perfusion imaging - a pilot study evaluating the transmural extent of perfusion abnormalities to predict atherosclerosis causing myocardial ischemia. Circulation Imaging. 2009;2:174–82. This study reported the diagnostic accuracy of CTA combined with CTP using a 64- and 256-detector CT compared to SPECT imaging and invasive angiography. CTP analysis included the use of a semi-quantitative transmural perfusion ratio of subedocardial to subepicardial attenuation.CrossRefGoogle Scholar
  17. 17.
    Kitagawa K, George RT, Arbab-Zadeh A, Lima JA, Lardo AC. Characterization and correction of beam-hardening artifacts during dynamic volume CT assessment of myocardial perfusion. Radiology. 2010;256:111–8.PubMedCrossRefGoogle Scholar
  18. 18.
    • Ko BS, Cameron JD, Meredith IT, Leung M, Antonis PR, Nasis A, et al. Computed tomography stress myocardial perfusion imaging in patients considered for revascularization: a comparison with fractional flow reserve. Eur Heart J. 2011. In this study utilizing the 320 detector CT, FFR during invasive angiography was used as the reference standard against which CTA and CTP were tested. Google Scholar
  19. 19.
    Habis M, Capderou A, Sigal-Cinqualbre A, Ghostine S, Rahal S, Riou JY, et al. Comparison of delayed enhancement patterns on multislice computed tomography immediately after coronary angiography and cardiac magnetic resonance imaging in acute myocardial infarction. Heart. 2009;95:624–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Goetti R, Feuchtner G, Stolzmann P, Donati OF, Wieser M, Plass A, et al. Delayed enhancement imaging of myocardial viability: low-dose high-pitch CT vs MRI. Eur Radiol. 2011;21:2091–9.PubMedCrossRefGoogle Scholar
  21. 21.
    le Polain de Waroux JB, Pouleur AC, Goffinet C, Pasquet A, Vanoverschelde JL, Gerber BL, le PolaindeWaroux JB, Pouleur AC, Goffinet C, Pasquet A, Vanoverschelde JL, Gerber BL. Combined coronary and late-enhanced multidetector-computed tomography for delineation of the etiology of left ventricular dysfunction: comparison with coronary angiography and contrast-enhanced cardiac magnetic resonance imaging. Eur Heart J. 2008;29:2544–51.PubMedCrossRefGoogle Scholar
  22. 22.
    Rodriguez-Granillo GA, Rosales MA, Baum S, Rennes P, Rodriguez-Pagani C, Curotto V, et al. Early assessment of myocardial viability by the use of delayed enhancement computed tomography after primary percutaneous coronary intervention. JACC Cardiovasc Imaging. 2009;2:1072–81.PubMedCrossRefGoogle Scholar
  23. 23.
    Marwan M, Pflederer T, Ropers D, Schmid M, Wasmeier G, Soder S, et al. Cardiac amyloidosis imaged by dual-source computed tomography. J Cardiovasc Comput Tomogr. 2008;2:403–5.PubMedCrossRefGoogle Scholar
  24. 24.
    Muth G, Daniel WG, Achenbach S. Late enhancement on cardiac computed tomography in a patient with cardiac sarcoidosis. J Cardiovasc Comput Tomogr. 2008;2:272–3.PubMedCrossRefGoogle Scholar
  25. 25.
    Christian TF, Frankish ML, Sisemoore JH, Christian MR, Gentchos G, Bell SP, et al. Myocardial perfusion imaging with first-pass computed tomographic imaging: measurement of coronary flow reserve in an animal model of regional hyperemia. J Nucl Cardiol. 2010;17(4):625–30.Google Scholar
  26. 26.
    Mahnken AH, Klotz E, Pietsch H, Schmidt B, Allmendinger T, Haberland U, et al. Quantitative whole heart stress perfusion CT imaging as noninvasive assessment of hemodynamics in coronary artery stenosis: preliminary animal experience. Invest Radiol. 2010;45:298–305.PubMedGoogle Scholar
  27. 27.
    George RT, Jerosch-Herold M, Silva C, Kitagawa K, Bluemke DA, Lima JA, et al. Quantification of myocardial perfusion using dynamic 64-detector computed tomography. Invest Radiol. 2007;42:815–22.PubMedCrossRefGoogle Scholar
  28. 28.
    Blankstein R, Jerosch-Herold M. Stress myocardial perfusion imaging by computed tomography a dynamic road is ahead. JACC Cardiovasc Imaging. 2010;3:821–3.PubMedCrossRefGoogle Scholar
  29. 29.
    Rocha-Filho JA, Blankstein R, Shturman LD, Bezerra HG, Okada DR, Rogers IS, et al. Incremental value of adenosine-induced stress myocardial perfusion imaging with dual-source CT at cardiac CT angiography. Radiology. 2010;254:410–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Okada DR, Ghoshhajra BB, Blankstein R, Rocha-Filho JA, Shturman LD, Rogers IS, et al. Direct comparison of rest and adenosine stress myocardial perfusion CT with rest and stress SPECT. J Nucl Cardiol. 2010;17:27–37.PubMedCrossRefGoogle Scholar
  31. 31.
    Tamarappoo BK, Dey D, Nakazato R, Shmilovich H, Smith T, Cheng VY, et al. Comparison of the extent and severity of myocardial perfusion defects measured by CT coronary angiography and SPECT myocardial perfusion imaging. JACC Cardiovasc Imaging. 2010;3:1010–9.PubMedCrossRefGoogle Scholar
  32. 32.
    Cury RC, Magalhaes TA, Borges AC, Shiozaki AA, Lemos PA, Junior JS, et al. Dipyridamole stress and rest myocardial perfusion by 64-detector row computed tomography in patients with suspected coronary artery disease. Am J Cardiol. 2010;106:310–5.PubMedCrossRefGoogle Scholar
  33. 33.
    Patel AR, Lodato JA, Chandra S, Kachenoura N, Ahmad H, Freed BH, et al. Detection of myocardial perfusion abnormalities using ultra-low radiation dose regadenoson stress multidetector computed tomography. J Cardiovasc Comput Tomogr. 2011;5:247–54.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Noninvasive Cardiovascular Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA

Personalised recommendations